Hey fam! Welcome back to the Nursing Code Lab Podcast. I hope everyone is having a beautiful day, evening, or night, depending on when you are tuning in. I am so glad you are here with me today.
Today, I want to talk about something that used to confuse me a lot when I was first starting out as a new nurse on the medical-surgical floor—and I know it’s something many of you struggle with as students or new grads. That big question: What is considered an emergency, in clinical practice?
Now, I’m going to share some clinical scenarios that you might come across and how to recognize when a situation requires quick evaluation and possibly immediate intervention. Because here’s the truth—when you’re a student or a new nurse, your number one goal is not to know everything—it’s to learn how to recognize when something is not right.
I still remember my preceptor telling me that when something deviates from the norm—even if you can’t exactly put your finger on what’s wrong—you need to trust your instinct and ask for help. That mindset helped me build my confidence and my nursing intuition over time. And now, many years later, I can often tell when a patient is starting to deteriorate—even before the labs or the vitals tell the full story. And that’s exactly what I want for you.
So today, we are going to walk through some basic scenarios. I’ll give you some examples to think about so that you can start sharpening your clinical eye. Ready? Let’s go!
Blood Pressure
Let’s start with vital signs, because you will be checking them multiple times a day, every day, and on every patient, plus it will tell us our patient’s hemodynamic status or if there is an underlying pathology. It will be a big part of your decision making process, in terms of who you may need to see or assess first. With the evolution of time, today we have early warning score tools, which consists of mainly vital sign abnormalities, to help predict if a patient will go into cardiac arrest and/or die within 48 hours of measurement, so being able to master the skill of critical vital sign interpretation will allow you to add another component to providing excellent care to your patient.
So let’s talk about blood pressure, the force that the patient’s circulating blood exerts on the walls of their vasculature. Your patient’s blood pressure is the product of cardiac output and systemic vascular resistance. And cardiac output is influenced by heart rate and stroke volume. We all learned in nursing school that a “normal” blood pressure is 90-120/60-80. But here’s the thing—what’s considered normal or abnormal really depends on the patient. This is why you should always want to ask your patient, “What is their normal blood pressure?” when you first meet them.
For example, if you have a patient whose baseline blood pressure is 95/65, and today they’re sitting at 130/80, and they are complaining of a headache, dizziness, or blurred vision. 130/80 might not seem that high for us as nurses, but it might actually be too high for your patient and that is why they are symptomatic. Now if you take the same patient and their blood pressure reading is like 85 systolic and they are asymptomatic we may not worry as much because it’s 10 points below what the patient’s normal usually run. But for the average person when the systolic number that goes less than 90 this should make you a little more concerned.
On the flip side, if you have a patient with chronic hypertension — someone who normally runs 150/90—and now their blood presure is 105/70, that’s a red flag. You’re looking at hypotension for this patient, who might also be symptomatic and that could be an emergency and requires immediate attention.
The big takeaway? Always know your patient’s baseline is and look for sudden changes. It’s not about one single number—it’s about trends and what is “normal” for that individual.
Heart Rate
Next up—heart rate. I love talking about heart rate, because this vital sign will almost always be the first to increase or decrease, when something is wrong with your patient. Heart rate is the number of times your patient’s heart beats per minute.
In general, a resting heart rate between 60-100 bpm is considered normal. But just like blood pressure, this also depends on your patient.
If you’re seeing a patient whose heart rate is trending up over time—say they were 80 bpm this morning and now they’re 120 bpm by the afternoon—that’s something that needs your attention. It could be related to pain, fever, dehydration, blood loss, or even early signs of sepsis. Or even maybe they have developed some form of an arrhythmia.
Likewise, with bradycardia (heart rate < 60 bpm) this could also be concerning especially if it’s new or your patient is symptomatic—like if your patient is dizzy, lightheaded, or has a decreased level of consciousness. But it also could be normal for the patient and they feel perfectly fine. Like for example my mother who normally has a HR of 45 -50 with a normal blood pressure , pretty much all her life, does not feel a thing. However if her resting HR goes up to 70 she feels it and she becomes symptomatic.
Now if your patient is hypotensive, tachycardiac and afebrile, this should trigger you to think that this patient has an abnormal heart rhythm. They could be in supraventricular tachycardia or atrial fibrillation, which is causing a decrease in cardiac output with the tachycardia. This is something that you would want to address immediately, because they may require medication or cardioversion to get their heart back into a normal rhythm.
And on the flip side if your patient is hypotensive, tachycardiac and febrile you need to consider if our patient is going septic.
So watch for the trends and how your patient is feeling. When in doubt, escalate and ask for help.
Respiratory Rate and Effort
Now, let’s talk about respiratory rate, the number of breaths a patient takes per minute, which is 12-20 bpm—this is one of the most under appreciated vital sign. I feel like we do not pay close attention to respiratory rates because it can be tricky as it can be voluntarily controlled by the patient. And I have experienced this with a patient of mine who was mechanically ventilated. Whenever he would get upset, he would hold his breath because he knew that it would set off the apnea alarms on the ventilator and the cardiac monitor. Another reason why respiratory rate is under appreciated is because often times we may see earlier changes in blood pressure and heart rate versus respiratory rate.
Also it is easier to narrow down on the causes of BP and HR changes vs RR changes, because respiratory rate is influenced by a large number of factors, basically any factors that impact the neural central control system, the sensory input system and the muscular effect system. But what you want to look for is what is their work of breathing like? Is your patient using accessory muscles? Are they gasping for air? Are they talking in full sentences or only in short phrases? Any increased work of breathing or respiratory distress is an emergency and needs to be treated right away.
Also—be mindful of a decreasing respiratory rate. A rate dropping below 10, especially with decreased level of consciousness, can be a sign that the patient is tiring out or going into respiratory failure. And again at this point we are looking at respiratory patterns.
Don’t ignore the breathing! This is the only way we can get proper gas exchange to take place in order to provide tissue oxygenation.
Temperature
Temperature is controlled by the hypothalamus and varies throughout the day based on your patient’s circadian rhythm and the environment. Normal range for temperature is 36 – 38 degrees. If the patient is hyperthermic you need to ask yourself is it infectious vs non-infectious and if the patient hypothermic is it because of decreased heat production, increased heat loss or impaired thermoregulation.
To me temperature adds a layer to my patient’s overall picture. In the clinical setting you mainly will be managing hyperthermia. Situations where you might be managing hypothermia would be if you just received the patient directly from the operating room, or a trauma patient, or maybe even end of life situations. No don’t get me wrong hypothermia can also be present in the setting of sepsis, but that would mean your patient is severely sepsis and the mortality rate is usually higher, so it usually is not a good sign.
Alright, so let’s say for example you noticed that your patient is hypotensive and they are also tachycardic. Your first question here is why is the blood pressure is low, and what is my patient’s heart rate trying to compensate for? It could be various reasons, but the first thought for me would be, is my patient losing blood volume because they are actively bleeding or because of vasodilation or is there an increase in metabolic demand. So when I see hypotension and tachycardia together in the absence of active bleeding or maybe just tachycardia I am reaching for a thermometer to do my patient’s temperature and I would say 80 – 85% of the time my patient’s temperature is elevated. And if the temperature is elevated I am now thinking that my patient it going septic and at that point we need to let the physician know so that they can do their own assessment. Is the patient’s hyperthermia because of their current condition or is it being cause by something that we as healthcare professionals are doing, meaning the insertion of any foreign object that we have introduced into the patient that has increased their risk of developing sepsis, for example CVC, foley, PIV, ETT etc… The Physician may also ask you to do some blood work so they can look at the WBC. IF elevated this adds to the level of confirmation around sepsis and if that;s the case they will ask you to do blood cultures.
So temperature is important to assess, as it plays a big part in the overall picture, it’s your body’s way of fighting off microorganisms that are harmful to the body.
Oxygen Saturation
The last piece of vital signs is the measurement of your patient’s oxygen saturation, which is the fraction of saturated hemoglobin relative to total hemoglobin being assessed. SaO2 is an incomplete measure of your patient’s respiratory status, because it does not assess ventilation (gas exchange). You would need to have an arterial blood gas to assess your patient’s ventilation status. Therefore you will not know for sure the status of your patient’s end organ perfusion, just by using the pulse oximetry.
As you have learned in nursing school, target Sa02 will vary based on your patient’s condition. For example if you have a COPDer your target Sa02 would be 88-92%, but if you have someone who is normally healthy with the same 88-92%, the next question would be why are they hypoxic. Your patient could be hypoxic for many reasons, such as environmental, or conditions that are causing hypoventilation, VQ mismatch, right to left shunting, or issues with diffusion.
Mental Status Changes
Other situations that would be considered emergencies or need addressing immediately are mental status changes and changes in urinary output.
If your patient was alert and oriented this morning and now they’re confused, agitated, or hard to rouse—that’s an emergency until proven otherwise.
Think about stroke, hypoxia, sepsis, hypoglycemia, or a new brain injury. Any sudden change in mental status—get your charge nurse and call the doc ASAP.
Urine Output
Urine output is another key indicator of how your patient is doing.
If you notice that your 75 kg patient, who was putting out 50 mL/hr, is now barely making 10 mL/hr—this could signal decreased kidney perfusion, dehydration, or even shock.
Always assess urine output in context with other vital signs.
When Should You Call for Help?
I want to end today’s episode with this important reminder:
If something in your gut is telling you that your patient is not okay—TRUST THAT. Never worry about whether you’ll look “silly” for calling for help. It’s always better to call early than to wait too long.
Some key situations where you should absolutely escalate quickly:
- Chest pain or new onset shortness of breath
- Acute drop in blood pressure or MAP
- Tachycardia or bradycardia with symptoms
- Sudden changes in mental status
- Increased respiratory effort or new oxygen needs
- Decreased urine output
- Uncontrolled bleeding
Alright fam, that is all I have for you today. Remember—your goal is not to know everything. It’s to recognize when something is off and to trust your instincts. You are building your nursing intuition every single day.
Thank you so much for tuning in to the Nursing Code Lab Podcast. If you found this helpful, share it with a fellow nursing student or new grad. Let’s grow this community and support each other.
Until next time, take care and keep learning!
Sources
https://www.hopkinsmedicine.org/health/conditions-and-diseases/vital-signs-body-temperature-pulse-rate-respiration-rate-blood-pressure
https://www.ncbi.nlm.nih.gov/books/NBK553213/
